Knowing the Why but not the How': A Dilemma in Contemporary Chinese Medicine - Brill
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Asian Medicine 5 (2009) 57–79 brill.nl/asme
‘Knowing the Why but not the How’:
A Dilemma in Contemporary Chinese Medicine
Jun Wang and Judith Farquhar
Abstract
This paper explores how modernisation of Chinese medicine has transformed Chinese medicine
doctors, as they like to say, from ‘knowing the how but not the why’ to ‘knowing the why but
not the how.’ Through unfolding the multi-faceted connotations and associations of these pro-
verbial formulas in the Chinese medicine field, we show the inevitable dilemma troubling many
Chinese medicine doctors, who feel they are stuck between the institutional demands of catching
up with the latest scientific knowledge and continuing the eminently effective features of Chi-
nese medicine in practice. The crisis of ‘knowing the why but not the how’ demonstrates that,
despite rather thoroughgoing scientisation, there are continuing conflicts between the modes of
knowing characteristic of Chinese medicine and modern science, which result from the assumed
hierarchy of knowing.
Keywords
Chinese Medicine, traditional knowledge, scientisation
Introduction
In parallel with the recent global movement of complementary and alternative
medicine (CAM) in the United States and Europe, ever more generous fund-
ing for scientific research on Chinese medicine is leading Chinese medicine
doctors in China to accelerate the production of scientifically-validated knowl-
edge.1 These activities not only engage them in serious dialogue with the inter-
national CAM community, but also create a higher profile of legitimacy for
the practice of Chinese medicine. Such strategies and recent successes might
begin to undermine the static, ‘traditional’ image that has long been projected
1
In contrast with the American medical system, there is no strict division between biomedi-
cal M.D.s and ‘doctors of Oriental Medicine’ in China. Chinese medicine doctors in general
hospitals and research institutes not only have sufficient Western medicine training and licenses
to practice Western medicine, but also compete with Western medicine doctors for TCM scien-
tific research funds. For detailed descriptions of the indistinct boundaries between TCM and
WM in China, see Scheid 2002 and Karchmer 2005.
© Koninklijke Brill NV, Leiden, 2011 DOI: 10.1163/157342109X568946
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as a contrast to modern Western medicine. However, after several decades of
all-out ‘scientisation’, the institutional privileging of Western scientific knowl-
edge in Chinese medicine research has produced a deepening predicament
among Chinese medicine experts. Borrowing diagnostic terms from Chinese
medicine, they often describe this situation as an ‘internal deficiency’ or more
specifically ‘a real shortfall within an apparent flourishing’.
In keeping with this anxiety, a recent controversial book entitled Contem-
plating Chinese Medicine (思考中医 sikao zhongyi) by Liu Lihong provoked
contentious debates about contemporary education in Chinese medicine in
China. Liu argues against the common belief that the only reliable value to be
found in Chinese medicine must come from modern scientific interpretations
and laboratory research; instead he argues that the scientific and philosophical
values of Chinese medicine are embedded in the field’s canonical texts. He
further claims that students and young doctors today have lost their confi-
dence in Chinese medicine as a result of alienation from its classical roots in
the process of increasing scientific assessment and standardisation of the field.2
His concerns echo those of many senior doctors whose reflections on the
effects of modernisation are quite poignant.
In interviews with Chinese medicine professors and senior doctors in China
between 2000 and 2002,3 specialists repeatedly invoked a language of crisis in
response to the question ‘What are the problems facing today’s Chinese med-
icine field?’ The most prominent concern is a decline in the quality of Chinese
medical skills with respect to their clinical practice and in-depth knowledge of
traditional medicine. Several senior doctors rhetorically phrased the problem
as ‘knowing the why but not the how’ (zhi qi suo yi ran er bu zhi qi ran, 知其
所以然而不知其然). In this expression ‘the why’ refers to modern scientific
knowledge, especially of causes such as the sites of lesions, and ‘the how’ refers
to the forms of existence and styles of practice of Chinese medicine, e.g. in
clinical traditions and textual sources.
The comment sounds rather spurious at first because it is a reversal of and
sarcastic play upon a common proverb ‘knowing the how but not the why’
(zhi qi ran er bu zhi qi suo yi ran 知其然而不知其所以然). The latter, origi-
nal form of the proverb refers to dangerously superficial knowledge, mere
technique without insight. For Chinese medicine doctors nowadays, how-
ever, reversing the terms of the proverb hints at a somber critique of the privi-
leged global-scientific approach to evaluating, modernising, and developing
2
Liu 2003.
3
Author Jun Wang interviewed about 50 Chinese medicine doctors from major Chinese
medicine colleges and hospitals of Beijing, Shanghai, Nanjing, Chengdu, Chongqing, and
Changsha during her ethnographic research in China.
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Chinese medicine. The contrast between the two proverbs is very poignant,
raising the most fundamental questions in Chinese medicine.
To practitioners, especially those who are aware of the textual tradition and
have experience of using Chinese medicine effectively, the question of what
kind of relationship Chinese medicine should maintain with Western medi-
cine is an open and conflicted one. They are understandably troubled by the
need to translate their expertise into a global idiom of bioscience and positivist
materialism. Can the efficacy of Chinese medicine, they ask, only ultimately
be accounted for with reference to the universals of biomedical anatomy,
physiology, and pathology? Or can metaphysical assumptions derived from a
classical literature—we will discuss some below—still provide a plausible
foundation for a practice in which they have much confidence?4
This paper provides some of the historical and social background that would
be needed to fully perceive the investment Chinese medical interviewees had
in this piece of wordplay. By considering the changing relation between a
clinical ‘how’ and a scientific ‘why’, one can explore some of the widest dilem-
mas of modernisation underlying Chinese medical work in China today.
Although the relationship between the philosophical foundations of any med-
ical practice and its clinical and practical expressions is not simple, i.e. the how
and the why of any medicine are never perfectly attuned, for Chinese medi-
cine, the problem of philosophical foundations is more complex. The belief
that modern doctors ‘know the why’ has resulted from the assumption of a
hierarchy of knowledge, i.e. ‘knowing the why’ is more important and inclu-
sive than ‘knowing the how’, as well as from the competitive relationship that
has developed over the past century or more between Chinese classical phi-
losophy and modern science.
Long before modern science posed questions of why anything is the way it
is, classical Chinese metaphysics, deploying concepts like Dao (the Way), yin
and yang, and the five phases, had laid the foundations of Chinese medicine.
This metaphysical logic was in place by the Han dynasty (206 BCE to 220 CE)
4
It has been noted by a number of authors that medical practice in China has been signifi-
cantly hybrid for a very long time, with ‘Chinese medicine’ incorporating European elements
even long before the nineteenth century introduction of missionary biomedicine and the rise of
a nationalist ideology of scientism in the early twentieth century (Karchmer 2005, Heinrich
2007, Scheid 2002). We also note, however, that the contemporary social life of medicine is
characterised by a great commitment on the part of experts of many orientations to maintaining
a clear distinction between ‘Chinese medicine’ and ‘Western medicine.’ Lay people also appear
to be quite comfortable with a continuing distinction between the two types of practice, even
when they mix, in any given treatment, elements from both. This continuing appearance of two
contrasting systems of medical care in China is important in part because of the philosophical
discomforts we document in this discussion.
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and provided a conceptual language that informed many indigenous Chinese
sciences and technologies. Classical cosmology was intertwined—sometimes
only implicitly—with clinical practice in all medical work. It was only com-
paratively recently, really in the twentieth century, that this long-standing lan-
guage of explanation encountered the crisis of legitimacy that now forms the
context of Chinese medicine practice.
Of course, the lament of elders that their trainees and followers are ignorant
and clumsy, as compared, perhaps, with their own teachers, is not a new phe-
nomenon. In some classical writing, all of Chinese history has been one long
decline from a golden age of perfect attunement between nature and human
(non)action. But new conditions of transmitting and institutionalising tradi-
tional Chinese medicine (TCM) suggest that medical craft is indeed changing;
it is little wonder that some feel this is not for the better. Textbooks and the
training provided for medical interns, for example, have radically standardised
and reified Chinese medical knowledge: correspondence tables linking symp-
toms to herbal drugs, for example, have banished both debate and creativity in
the world of formulary ( fangjixue 方剂学); and an infinite number of possi-
ble names for pathological conditions have been simplified to nosological
tables of disease-like illness patterns (zhenghou 证候). For newly standardised
patterns, moreover, there are entailed treatment protocols. These develop-
ments have unified and systematised the Chinese medical field, but a senior
generation of physicians, not trained quite so systematically, worries that
younger doctors are mere technicians rather than creative and responsive
healers. Both of us know some rather uncreative senior doctors and some very
erudite and inspired younger ones; but the concern about a declining clinical
craft still makes sense.
Since the 1950s, and very intensively since the 1990s, modern scientific
models and research methodologies have been deployed strategically by major
TCM policy makers, i.e. the Ministry of Science and Technology, the Minis-
try of Health, and the State Administration of Chinese Medicine. In the past
two decades, under a mandate of ‘supporting the modernity of Chinese med-
icine through technology innovation,’ textbooks and medical school training
both teach and presume the knowledge produced in laboratory and clinical
research in order to ‘buttress Chinese medicine in its clinical practice and to
propose new theoretical frameworks for the known techniques of the field’.
In the Guideline for the New Development of Chinese Medicine 2006–2020,
Chinese medicine is expected to become one of the breakthroughs as Chinese
science and technology heading forturns toward the world.5 It seems as if
5
The guideline, ‘中医药创新发展规划纲要 2006–2020’ in Chinese, was jointly released
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‘Chinese medical science’, a new name that has been used frequently in official
accounts, will gradually replace the old name ‘traditional Chinese medicine’ in
the near future. In the eyes of Chinese medicine’s most experienced clinicians,
the results of this form of development are perhaps inevitable, but nevertheless
far from desirable.
Historical and cultural connotations of the ‘how’ and the ‘why’
The origin of the proverb, knowing the how but not the why, is linked with a
third century ( Jin dynasty) scholar named Tao Yuanming (陶渊明). As a
Daoist, he advocated that learning (in the form of reading) could only be
rewarding and enjoyable if one was not bothering to understand the why. On
the face of it this seems an odd argument. Why would a serious thinker like
Tao Yuanming specifically eschew knowing why the world appears as it is? Was
he too lazy or stupid to inquire into the hidden depths of knowledge? Or is it
that ‘the why’ is constitutively inexplicable and self-effacing? According to
early Chinese cosmogonic views attributed to Laozi (Lao-tse, about the sixth
century BCE), dao, the inexhaustible generative underlying dynamic of being,
itself invisible and inexplicable non-being (wu 无), produces all beings (wanwu
万物) and populates the universe. To embrace Dao is to live with relative non-
action (wuwei 无为), or to live in accord with spontaneous, uncaused natural
process. Thus for a Daoist like Tao Yuanming, knowing the how but not caring
to know the why bespoke a philosophical premise that set radical limitations
on language, logic, and reasoning. These limitations on knowledge and what
could be spoken of, accompanied by a lively and articulate interest in the
forms and dynamics of the manifest world (the wanwu), became important
foundations for much of Chinese thought and especially, as we note below, its
indigenous sciences. There are many concepts similar to Dao, still in quite
common use in Chinese, that are considered essentially difficult to define or
exhaustively explain; examples are qi (气 breath, energy, configurative force),
shen (神 vitality, spirit, consciousness), xin (心 heart-mind), and taiji jin
(太极劲 soft internal force that results in great strength). This philosophical
silence about important processes extends to some feelings as well. It is often
observed in the West that Chinese seem reluctant to give voice to deep feel-
ings, such as love. Whether or not this is true, Chinese people often find
by 16 major Chinese government administrations including the SATCM administration on 21
March 2007, superseding the similar directive guideline of 2002. Both focus on the modernity
(xiandaihua) and internationalisation (guojihua) of Chinese medicine. See Journal of Chinese
Medicine Management, (中医药管理杂志), 2007, vol. 4, pp. 225–30.
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Western ways of expressing emotions unnatural and pretentious. As Laozi
asserted: ‘The way that can be spoken of is not the constant way, the name that
can be named is not the constant name.’6
The notion of Dao not only inspired countless poets and artists, but also
had a tremendous influence in the ancient Chinese sciences, especially Chi-
nese medicine. The idea of living in harmonious accord with natural processes
is considered by Chinese medicine doctors to be the highest achievement of
well-being. Because the world and human beings are constantly changing fol-
lowing the underlying mutuality of yin and yang (which is the expression of
the dynamic Dao), we need not inquire into the causes of things, only learn to
perceive and work with the correlations of their forms.7 In many kinds of
traditional Chinese learning, an intuitive comprehension of the patterns of
natural dynamics, like the understanding one might have of music, has been
seen as the key to grasp the pivot ( ji 机) of the correlations that give form to
both the healthy and the ill body. Freiberg, for example, has explained the
value of intuitive knowing in The Daoist Mind: ‘Intuitional understanding is
more reliable than knowledge, for the latter serves at best to complement the
former, while at worst it confuses the mind with artificial distinctions and
reifications.’8
This is not to say that in the course of 2000 years of medical practice and
lavish record-keeping Chinese doctors failed to systematise, rationalise, or
theorise their work. In fact during the several millennia in which Chinese
medicine developed as an indigenous East Asian sphere of knowledge,9 lively
debates about proper techniques and the reasons for their desirability pro-
duced a vast archive of systematic medical thought that is still drawn on today.
But Sean Lei has noted that an intuitive way of knowing came to be particu-
larly re-valued in the practice of Chinese medicine in the twentieth century
when Chinese medicine has to emphasize its own special subtlety against the
literal-mindedness of Western medicine.10 An experiential approach to under-
standing and practice in Chinese medicine has also been noted by Farquhar,
who found that practitioners in the 1980s referred to adept clinical skill with
the term linghuo (灵活), meaning flexible, sensitive, or responsive. She explains
6
Translation: Lau 1963.
7
Major 1993, Kaptchuk 2000.
8
Freiberg 1975, pp. 304.
9
Note, however, that until the modern period beginning in the nineteenth century medicine
was not often set apart as a particular sphere of expertise. Its historical development cannot be
readily separated either from the history of other elite forms of self-cultivation or from very
diverse modes of popular healing. See Sivin and Lloyd 2003.
10
Lei 2002, pp. 333–64.
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why flexibility and responsiveness were more valued in Chinese medical prac-
tice at the time than rigorous explanations:
Chinese medical action is thus intrinsically temporal and activist; intervention is
required in every pathological yinyang situation as the illness develops, and the
state of play must often be reevaluated in the expectation that new excesses and
deficiencies will develop. . . . For Chinese medicine contingency is not what threat-
ens a course of treatment but rather what shapes it.11
These observations are consistent with Chinese science historian Liao Yuqun’s
argument that the key to understanding Chinese medicine is to understand
the application of the mind, yi 意.12 Yi, both a noun and a verb in Chinese,
means ‘in the mind of ’, ‘the mind’, or even ‘to think or entertain ideas’. Prov-
erbs using the term and allied notions, such as ‘the heart-mind responds and
the consciousness understands’ (xinling shenhui 心领神会) and ‘medicine is
mind’ ( yizhe yi ye 医者, 意也), are often invoked by Chinese medicine doc-
tors to justify the judgments they make in practice.
The earliest Chinese medicine text that talks about medicine and the mind
is the Guoyu Zhuan (郭玉传).13 Guoyu was an accomplished imperial doctor
(active around the second century CE) who adapted the proverb ‘medicine is
mind’ to speak of the great degree of intuition involved in practicing medi-
cine. He said:
To speak about what medicine is, it is the mind. The networks of the skin (cou li
腠理) are extremely delicate and subtle (zhiwei 至微). Therefore, [a good acu-
puncturist] follows the qi [perceptible through the needle at the acupoint] and
applies sensitive techniques.14
This interesting and very classical statement suggests that for Chinese medi-
cine doctors, presence of mind involves a kind of participation in the flow of
qi, not only in the body of the doctor but in that of the patient to whom he is
connected by way of acupuncture needles. Perhaps, then, mind is the point at
which language meets its limit in approaching the vicissitudes of the body and
disease. Shigehisa Kuriyama, in his comparison of ancient Chinese and Greek
pulse perceptions, has argued that the two cultures diverged into a world of
perceptions and a world of facts. Chinese doctors expressed their perception
11
Farquhar 1994a, p. 168.
12
Liao 2006.
13
Fan Ye 5 CE, ‘The Biography of Guoyu’, History of the Latter Han.
14
Couli (腠理) here stands for the qi-responsiveness of the body as a whole. Cou literally
means the invisible spaces of the skin and li the visible fine lines of the skin. The original Chinese
text is: ‘医之为言, 意也. 腠理至微, 随气用巧.’
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of the pulse through figurative and allegorical language, which posed tremen-
dous challenges and doubts for a modern and European culture that valued
literalness and clarity in language:
Once speaking is conceived as the expression of ideas in the mind, then the hun-
ger for transparency becomes irresistible—though it remains ever insatiable,
though we cannot peer into other minds. Does your idea of ‘undulating’ corre-
spond to mine? We simply cannot know.15
Kuriyama’s discussion reminds us of some assumptions that underlie many
modern critiques. A Chinese medical approach is often criticised as an ‘over-
imaginative’ and ‘unreliable’ form of knowledge when it is reflected in the
mirror of a modern approach committed to objective, clear, representational
knowledge. But Chinese medicine professionals know beyond any doubt that
their medical practices are effective, even if they are difficult to standardise and
explain in biomedical language. It is the widely acknowledged usefulness of
Chinese medicine therapies, especially for the management of chronic ill-
nesses, that has not only helped this ‘traditional’ field grow and flourish in the
People’s Republic of China but has begun to make it globally important as
part of the CAM movement.
The defeats of imperial China by the Western colonial powers in the end of
nineteenth and early twentieth centuriesy prompted the acceptance of West-
ern social and political values in the first half of the twentieth century. Under
this context, and as a result of the rapid rise in influence of Western science
and medicine in China, Chinese medicine was often denounced as unscien-
tific and its theory was at times characterised as pure conjecture. In regard to
the profound influence of Western science, and the rise of ideological ‘sci-
entism’ in China between 1900 and 1950, D. W. Y. Kwok insightfully
observed: ‘Scientism exhibits first, a particular understanding of the power of
science, second, a critique of tradition, and, third, a form of substitute
religion’.16 Modern scientific philosophies and methodologies have been priv-
ileged throughout the twentieth century, seen as indisputable doctrines by
Chinese intellectuals, most of whom believed that only scientific beliefs and
practices could address the dire difficulties facing Chinese society in the early
twentieth century. In searching for an integrated, competitive, and modern
identity, Chinese reformers in the early-to-mid-twentieth century advocated
the abandonment of traditional Chinese world-views along with the old impe-
rial social-political structures. Chinese medical views of the world and the
human body, seen at best as based on abstract, speculative, and inductive
15
Kuriyama 1999, p. 81.
16
Kwok 1965, p. 30.
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methods, were held to be essentially incongruous with modern scientific views;
these were, in their turn, held to be based on concrete, quantitative, and
deductive methods. The attitudes Kwok calls ‘scientism’ presume that only
scientific methods (laboratory experimentation, clinical trials, statistical analy-
sis, and so on) can produce true knowledge. Therefore, ‘unscientific’ became a
derisive label that Chinese medicine has had to bear since the beginning of the
twentieth century. However, even for the most virulent scientific critics of
Chinese medicine, its usually benign clinical effects remain undeniable.
It is the theoretical framework of Chinese medicine, however, that has been
the target of the most destructive and skeptical criticisms. Under these condi-
tions, then, knowing the how but not the why gradually became a negative
designation, losing touch with its Daoist philosophical roots and coming to
refer to a dangerously superficial level of knowing in contrast with profound
structural and rational knowing. Scientific critics readily used this proverb to
refer to those who had not yet been enlightened by science. Despite philo-
sophically sophisticated resistance on the part of Chinese medicine doctors,
then, it came to be widely believed that although they could treat patients
effectively in the clinic, they didn’t know why their methods worked or did
not work.
Acupuncture is a good example: this technique combines a startling effec-
tiveness, sometimes an ability to eliminate pain or other discomforts instantly,
with an enduring puzzle for scientific evaluators. The circulation tracks pos-
ited by the classical Chinese acupuncture model have no anatomical existence.
There is no structural reason why needling a point on the leg should alter sen-
sations in the neck or abdomen. Efforts to explain acupuncture effects with
reference to the release of endorphins can neither address the specificity of
acupuncture effects in relation to particular points nor account for its clear
effectiveness for conditions not requiring pain relief.17 One of the paradoxes
from decades of acupuncture research by Western scientists is that an increas-
ing number of large clinical trials have reported that true acupuncture does
not significantly outperform sham acupuncture, which is at odds with the
therapeutic outcomes and traditional theories of acupuncture treatment.18 In
the absence of a biomedical rationale, acupuncture efficacy has sometimes
been seen as no more than placebo effects. Although researchers have started
to question the assumption that acupuncture research should be conducted
and judged according to the methodology of conventional clinical trials, long-
standing doubts about Chinese medicine theory—persistently seen as lacking
17
Shang 2009, pp. 31–9.
18
Wayne and Hammerschlag 2009, pp. 1039–44.
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an adequate vision of ‘the body’—thus haunt today’s practitioners and
scholars.19
Opponents of the legitimacy of Chinese medicine have attributed its clini-
cal effectiveness to long-term practical experience (i.e. knowing the how) while
they have denied that its theoretical frameworks (such as yin-yang and five
phases forms of analysis) could have any rational coherence. In other words,
Chinese medicine came to be seen as being completely ignorant of ‘the why’
underlying its work because all its actual ‘theories’ were false. This is a typical
modernist construction of others, and many critics writing in both Chinese
and English have challenged these facile dismissals of the Chinese medicine
heritage.20 In addition, as Lei and Taylor have shown, modern Chinese gov-
ernments (both the Nationalist government in the Republican Period, 1911–
1949, and that of the People’s Republic) have been active in shaping Chinese
medicine to the political and economic circumstances of modern Chinese
society.
After the People’s Republic of China was established in 1949, Communist
Party health policy called for an integrated new medicine whose primary
concern should be serving the vast rural Chinese population. Significant
efforts were made to incorporate Chinese medicine into the national health
system and to resolve antagonisms that had developed between the fields of
Chinese and Western medicine. Taylor argues that the appearance of today’s
TCM was a direct and instrumental result of Chinese Communist Party’s
imperative of serving the new PRC society under grim political and economic
circumstances.21 However, from a broader historical perspective, the ideology
of modernity which accompanied the PRC’s economic and political recon-
struction, inevitably undermined the epistemological roots of traditional Chi-
nese medicine.22
The ‘unscientific’ stereotypes of Chinese medicine didn’t go away when
mid-century efforts to abolish the field were ended and its institutional status
was upgraded; rather these stereotypes were reinforced in a new way in social-
ist China under the sway of Marxist doctrines of materialist science. Many of
the senior doctors Jun Wang interviewed attended ‘advanced training courses’
in the 1950s. These schools were defined as ‘bridge education’, the aim of
which was to help traditional doctors to improve both their political con-
sciousness of socialism and their knowledge of Western medicine. The meta-
phor ‘bridge’ vividly indicates the function these advanced schools were to
19
Farquhar 1994b, pp. 78–99. Farquhar and Margaret Lock (ed.) 2008, ‘Introduction’.
20
Sean Lei 2002, Zhan 2001, Taylor 2004, Karchmer 2005, Scheid 2007.
21
Taylor 2004.
22
Unschuld 1992, p. 46.
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fulfill: not only were they meant to transform unscientific medicine into sci-
entific medicine, they would also transport the ‘old’ medical personnel into
the modern era. A letter to the editor reflecting the hopes and values of the
time, written by a doctor seeking bridge training, was published in a Chinese
medicine journal in 1952:
I am a Chinese medicine doctor and I believe from my own experience of clinical
practice that Chinese medicine is definitely effective. But I haven’t been able to
find theoretical reasons from the classics of why I can treat diseases successfully.
And this is why I wanted to attend an advanced school. I hope I can use scientific
knowledge or modern medical theory to improve the treatments of Chinese
medicine.23
This rather typical admission reflects the negative connotations of knowing the
how but not the why. Though knowing the how and perhaps remaining agnostic
about the why had presumably always been desirable in the practice of Chinese
medicine, around this time knowing the ‘scientific why’ came to be the mod-
ernising heart of Chinese medicine. Many Chinese medicine doctors inter-
preted ‘bridge’ training as a way of transforming the imperfect practitioner
who ‘knows the how but not the why’ into an advanced practitioner who
could ‘know both the how and the why’ of Chinese medical therapies. It is
believed that once Chinese medicine doctors knew why something worked in
terms of a consistent scientific theory (even one that had been much altered in
its translation), it was presumed that their practice would not only become
more grounded, it would become more effective. But given the deep historical
differences between the two systems of medicine, this goal was not easy to
achieve by Chinese medicine doctors alone.
For a time between the 1950s-1970s, much hope was pinned on research
into the unification of Chinese and Western medicine (zhongxiyi jiehe 中西医
结合).24 The initial unification personnel were primarily Western medicine
doctors who studied Chinese medicine (西学中) in the 1950s and 1960s.25
Their scientific research sought to work less at the level of proving the
23
Shen 1952, p. 13.
24
Unification of Chinese and Western medicine was the primary way of developing medicine
in Mao’s China. After the end of the Cultural Revolution in 1976, a new state policy emphasised
developing ‘three roads for medicine’ i.e. Western medicine, Chinese medicine, and unified
medicine. Each form of medicine has developed through more or less independent institutional
structures since then, but unified medicine has not flourished. For a detailed history, see Wang
2002.
25
During the 1950s, thousands of Western medicine doctors were trained in Chinese medi-
cine full time in courses ranging from three months to three years. Subsequently, they partici-
pated in both scientific research and clinical practice on the unification of Chinese and Western
medicine (Zhao 2007).
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effectiveness of Chinese medicine therapies than synthesising the theoretical
foundations of the two systems. Examples are projects on ‘using cAMP/cGMP
to explain the physiological and pathological basis of yin-yang effects’26 and
‘researching the [structural] nature of the kidney (肾本质) and other Chinese
medicine organs.’ However, alongside these efforts to provide Chinese medical
entities with biomedical counterparts, a more successful form of unification
research was taking place, in clinically oriented projects. Most clinical research
at this time focused on improving the treatments for certain common diseases,
including both acute and chronic conditions. For example, successful research
projects within unification medicine (using both Chinese and Western medi-
cines) developed techniques for treating acute abdomen (急腹症), small board
setting techniques for upper limb bone fractures (小夹板固定治疗上肢
骨折), herbal treatments for high blood pressure and cardiovascular diseases
(高血压和心血管疾病), and therapy for hemorrhoids and hemorrhoidolysis
(痔疮和痔漏) (Chinese Health Year Book 1978–2005). It is interesting to note
that early unification medicine focused more successfully on the how than on
the why. Researchers from both medicines at that time of mobilisation to ‘serve
the people’ were more concerned with maximum clinical effectiveness than
with the mechanisms that might be taken to underlie the combination. The
task of ‘knowing the why’ with any degree of comprehensiveness was deferred,
passed on to future generations of doctors.
From 1956 to 1965, twenty-two colleges of Chinese medicine were estab-
lished nationwide. The curriculum of these colleges at first reflected the same
themes as ‘bridge’ education and unification medicine had. An increasing
number of policy makers and members of the general public came to believe
that the old problem of ‘knowing the why’ would be solved by a college educa-
tion that included a significant proportion of training in the Western biosci-
ences. Somehow, the new experts themselves would embody a coherent
synthesis. This strategy for the development of modern Chinese medicine was
soon interrupted by the outbreak of the Cultural Revolution in 1966, and
modern college education in the sciences was not restored until 1978, when
Deng Xiaoping came to power.
26
cAMP/cGMP are both cyclic nucleotides of cells, and respectively stand for cyclic adem-
osine monophosphate [cAMP] and cyclic guanosine monophosphate [cGMP], which are the
two most important ‘second messengers’ involved as a modulator of physiological processes, such
as regulating neuronal, glandular, cardiovascular, immune mechanism, nervous system, cell
growth and differentiation. In general, Chinese researchers concluded that cAMP and cGMP
have a similar yin-yang regulating relationship in which cGMP performs yin and cAMP performs
yang.
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The contemporary dilemma
During the 1980s and under the influence of Deng Xiaoping’s famous eco-
nomic ‘opening and reform’ ( gaige kaifang 改革开放) policy, summed up in
part with the slogan ‘achieve the four modernisations,’ Chinese citizens enthu-
siastically engaged in the revival and rebuilding of academic activities and
structures. The Chinese medicine field also experienced a complex revival,
even including a celebration of ‘traditional’ knowledge. A master’s degree pro-
gram was set up for the first time at the Beijing College of Chinese Medicine
in 1981 and in other colleges of Chinese medicine at about the same time.
PhD programs were begun in the later 1980s.
As Judith Farquhar witnessed while conducting fieldwork at a major Col-
lege of Chinese medicine in the early 1980s, the early reform era saw a very
influential ‘epistemology and methodology’ (renshilun he fangfalun 认识论和
方法论) movement in the Chinese medicine field that critically explored
‘modes of thought’ (siwei fangshi 思维方式) and valorised the scholarly and
clinical experience of senior doctors. For nearly two decades (from the 1980s
through the1990s) senior Chinese medicine doctors enjoyed an exalted status
in some circles under the new official rhetoric of ‘inheriting and carrying the
heritage forward’ of traditional Chinese medicine.
However, since the mid-to-late 1990s, the heritage of senior doctors, includ-
ing their highly praised clinical skills, knowledge of the classics, and personal
cultivation in traditional arts, has lost much of its importance, as scientific
skills are being re-valorised in the new era of globalisation and Chinese medi-
cal modernity. Volker Scheid points out that since the 1990s, the highest pri-
ority for China and Chinese medicine has been to ‘get on track with the world’
(跟世界接轨), to integrate into the networks of the emergent global economy
and medical market. This popular imperative has again reshaped Chinese
medicine:
In practice, this meant that regulation, standardisation, and bureaucratisation
acquired a new urgency. . . . [M]ultiple directives were passed that defined national
standards in diagnosis and treatment: research mirrored on scientific paradigms
became the only acceptable way.
Most graduate students in the universities of Chinese medicine nowadays
spend most of their time on scientific research, using methods such as animal
models, molecular genetics tests, and statistical analysis. Scientific methodol-
ogy, many of the younger generation argue, can be used to help develop Chi-
nese medicine in the same way as it is presumed to have helped Western
medicine in history (though we wonder whether the complex relationship
between experimentation and established knowledge in history has really been
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so simple).27 In Chinese Medicine and its Modernisation Demands, three
researchers on Chinese medicine, writing in English, encapsulate these mod-
ernisation beliefs in today’s global Chinese medicine field:
TCM modernisation has become necessary and urgent. Modernisation of TCM
means the combination of TCM with modern technology, modern academic
thought, and modern scientific culture, in which the most important point is to
elucidate the active component of TCM, especially the material foundation of
compound prescriptions and their pharmacodynamic mechanisms. Technology
of analytical chemistry (HPLC, HPCE, HSCCC, etc.) and molecular biology
(patch clamp, gene clamp, gene chip, fluorescent probe, DNA TUNEL assay, in
situ hybridisation, etc.) are useful tools to realise the modernisation of TCM.28
To many modernisation advocates, science and technology are the undeniable
solutions to problems presented in the development of Chinese medicine. In
other words, after the program of unification with Western medicine was
more or less abandoned in the 1990s, Chinese medicine embarked on the
‘road’ of integration with ‘pure’ science and technology. What seems to be
imagined, however, is a full translation of Chinese medicine concepts and
entities into those of global bioscience.
But these scientific endeavors have brought few benefits, and arguably
much confusion and disorganisation, to Chinese medical traditions and prac-
tices. The irony of the reversed proverb, ‘knowing the why but not the how,’
targets the new generation of Chinese medicine doctors who increasingly seek
to demystify ‘the why’—filling the category with a biomedical body and scien-
tifically validated data about it—but who don’t know much about the nuances
of clinical practice. In reality, most doctors think Chinese medicine is under-
going a dreadful decline of its living tradition of clinical skills and classical
knowledge. The failure to know ‘how’ evokes other questions about what it
could really mean to know ‘why.’ Is science, for example, really able to answer
the question of why Chinese medical therapies work as they do? Reflecting on
their field over the past two decades, many doctors have been suspicious of the
program that seeks progress through science, though they have not always felt
free to express their views openly. Among interviewees, a dean of a university
27
Recent scholarship in the history of medicine has shown that a sharp Western/indigenous
divide is particularly problematic, tending to continue a prominent nineteenth-century dis-
course of medical modernisation. In addition, biomedicine’s espousal of scientific method as the
sole basis for its authoritative claims to effective expertise has not been established as objectively
and scientifically as most people think. For a lively and up-to date exploration of medical plural-
ity, see papers by Bradley, Arnold & Sarkar, and Scheid in Plural Medicine, Tradition and Moder-
nity, 1800–2000 (Waltraud Ernst (ed.) 2002).
28
Li, Jiang and Chen 2008, pp. 246–51.
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of Chinese medicine expressed this frustration rhetorically and extended his
sense of contradiction to wider inquiries:
• Why is it that the ‘bewildered’ (hutude 糊涂的) [senior doctors] can cure
patients, and the ‘enlightened’ (mingbaide 明白的) [younger doctors] can
not?
• Why is it that herbs which were dismissed by laboratory research as having ‘no
medical effects’ (无疗效的) are the ‘key medicine’ (主药) in the classical for-
mulas that remain the most effective remedies?
• Why is it that herbs which have been demonstrated by laboratory experiment
as ‘having medical effects’（有疗效的) can’t treat disease unless they are com-
bined in classical formulas with [laboratory experiment demonstrated as] ‘use-
less’ (没用的) ones?
His questions arise from the results of massive amounts of scientific research,
especially that recently done by international pharmaceutical companies in
search of new drugs for managing chronic diseases. He draws attention to the
fact that the scientific mechanism behind herbs and herbal medicine formulas
has never been clear or really verified, due to methodological difficulties.29 In
classical theory, the actions of Chinese herbs are defined by ‘four qi and five
flavors’ (siqi wuwei 四气五味), attributes of drugs that can vary with a variety
of processing procedures, combinations with other drugs, and geographical
regions of origin. Chinese doctors using herbs in real clinical settings are
described as ‘generals deploying soldiers’ (用药如用兵) on a battlefield. In
other words, whether herbs/soldiers are useful or not depends largely on how
they are used by strategists. The dean’s rhetorical questions ultimately reveal
the incompatibility between two rationalities: the styles of thought and knowl-
edge production that still differentiate Chinese medicine from modern
bioscience. These are, thus, key questions underlying the central dilemma of
the field.
Much recent research on CAM, especially on herbs and natural plants,
poses similar questions and expresses similar doubts about the feasibility and
outcome measurements of conventional scientific methodology. For example,
long time CAM researchers Walach, Jonas and Lewith point out that double
blind trials, initially created and used by the pharmaceutical industry to test
single components of chemical drugs, are by no means suitable to test the
therapeutic effectiveness of Chinese herbal formulas and other alternative
29
For example, traditional Chinese medicine doctors prepare herbal remedies with whole
herbs instead of herbal extracts (as in pharmaceutical labs). However, natural herbs are not rec-
ognised as drugs by the Food and Drug Administration, which requires that a drug be identified
as a single chemical entity (Wu 1995, p. 172).
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therapies, due to the complex nature of whole herbs.30 However, under the
hierarchies of scientific discourse, other rationalities, such as the ancient meta-
physics and holistic views that underpin Chinese medicine, provide no ground
of comparison. They can only be disbarred from contributing anything to
medical explanation.31
Of course, we should keep in mind that not all younger Chinese doctors fall
into the category of those who ‘know only the why.’ The scholar/doctor Liu
Lihong mentioned above belongs to the younger generation of Chinese medi-
cine doctors. The majority of Chinese medicine doctors work in less privileged
clinics and away from the major cities. They have little access to scientific
journals or other sources of up-to-date research in their field. It does not fol-
low, of course, that they therefore know better how to practice Chinese medi-
cine with nuance and responsiveness. However, as Karchmer, Zhang, Scheid
and others have shown, elite doctors’ practices and the institutional develop-
ment of scientific knowledge have made a significant impact on the practice of
Chinese medicine in general, so even ‘rural’ doctors have been formed within
a scientistic environment some critics would call degraded.
A case study
Dr. Luo, a clinician and an editor of a Chinese medical journal, told me that
her graduate training was spent in a lab instead of in the library with the clas-
sics of Chinese medicine. She entered a University of Chinese Medicine in
northeast China as a PhD student in the Huangdi Nei Jing (Yellow Emperor’s
Inner Canon) Department in 1997.32 Under her supervisor’s instruction,
she and her classmates designed a research project on the ‘constraint’ syn-
drome ( yuzheng, 郁 证). This illness category is often vaguely translated as
30
Walach, Jonas and Lewith 2002, pp. 29–46.
31
In contrast to how they have been perceived in China, Chinese herbal remedies marketed
in the USA have been denounced as ‘unknown’ and ‘risky’ for American consumers. For exam-
ple, it has been argued that because of the lack of quality control from the FDA, adulteration,
substitution, and contamination are possible or even likely in Chinese herbal products (Sardesai
2002, pp. 343–8). There have indeed been some scary episodes of abuse of Chinese herbs in
recent years. One example is the use of large doses of ephedra 麻黄 for weight loss, which has
apparently caused kidney damage. Because such cases have been linked to a lack of regulation
and recognition of Chinese herbs as drugs by Western health care administrators, and to abuse
by practitioners or users, critics argue that Chinese herbal medicine as a whole should be
eschewed.
32
The Inner Canon department is not just a scholarly department concerned with this
2000-year-old text and its redaction; it is responsible for certain types of clinical and scientific
research stemming from the ‘fundamental theory’ contained in the Inner Canon.
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depression in English in order to fit into Western medical terminology.33 In
Chinese medicine, whether yuzheng is equivalent to depression is a controver-
sial question. In Chinese medical diagnostics, the syndrome tends to be seen
as the result of liver qi stagnation (肝郁气滞), a physiological state that can-
not be translated into biomedical etiologies for ‘depression.’ Notwithstanding
the oft-noted incompatibility between the names of diseases in Chinese medi-
cine and in Western medicine, the Chinese medicine zheng (differentiated
syndrome) and Western medicine bing (disease, illness) are combined, or
mapped over one another, in many research and clinical practices. In Dr. Luo’s
project, yuzheng was assumed for all practical purposes to be equivalent to
depression.
According to the Inner Canon, or Nei Jing, yuzheng is a yin syndrome, and
thus should be rectified by applying some form of counter-acting yang. There-
fore, doing acupuncture on yang channels is often a first principle in the treat-
ment of depression. Luo’s research aimed to demonstrate that this simplified
version of classical theory could be confirmed with a scientific methodology.
Her experiment had two components: first, to determine if depression was
consistently classifiable as a yin syndrome (thus reducing the infamous vari-
ability of Chinese medicine diagnosis, its sensitivity to the vicissitudes of place,
time, and person) and second, if it was, to test the success of treating this sta-
bilised condition via one consistent method of yang channel acupuncture. For
the second component they chose the du meridian (督脉), the governing
( yang) channel of the human body, as the research focus. They located the
acupuncture point baihui (百会穴), the crossing point of all the yang merid-
ians on the top of the head, as the key treatment point on the du meridian.
The experiment was done on white mice.34 The first step was to generate a
‘depression model’ in the mice. They put the mice in a noisy environment and
then forced them to swim in icy water. After repeatedly undergoing this tor-
ture for a week, these mice were believed to have a depression syndrome, as
manifested in their changed eating habits, movements and other behaviors.
Then the ‘depressed’ mice were divided into one control group and several
other groups for comparison. For example, group one was treated with
33
Arthur Kleinman argued in the 1980s that due to the somatopsychic cultural view of self
and body, depressive disorder, which is the most common diagnosis in American psychiatrist
clinic, was rarely used by either patients or doctors (both Chinese and Western medicine) in
China: ‘Depression . . . was the result, not the cause, of pain, a medical not a social psychological
problem.’ (Kleinman 1985, p. 468).
34
This gesture also incorporates a huge assumption, that the mouse body has channels of
qi flow that are exactly analogous to those of the human body. Acupuncture researchers acknowl-
edge that this is a problem, but it doesn’t prevent them from using animal models in their scien-
tific research.
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acupuncture on a yin channel, group two with herbal medicine, and group
three was treated at the baihui point. A control group of ‘depressed’ mice lived
normally without any treatment. After two weeks of treatments and no more
torture, the results showed that the group with acupuncture on the baihui
point recovered from depression the fastest. Based on the data from this suc-
cessful experiment, Luo’s thesis about the validity of ancient knowledge from
the Nei Jing was confirmed. Her project qualified as ‘modern research on Chi-
nese medicine theory.’
Although Luo thinks that the laboratory skills she learned in graduate
school could be beneficial to her future work and ‘knowledge structure’ (知识
结构), she doesn’t think that the findings will benefit the general knowledge
or practice of Chinese medicine. In this case, her results were not surprising;
they were consistent with traditional knowledge, so nothing much was added
to Chinese medicine therapies. Even if the results had been inconsistent with
Chinese medical theory, it would have been impossible to adjudicate which
way of knowing was correct, because Chinese medicine theory is still sup-
ported by its clinical efficacy, and because there were so many distortions of
clinical medicine built into the laboratory research design.
People sometimes say that when scientific research gives results inconsistent
with TCM, traditional knowledge will be called into question. However, in
the past two decades, clinical practices designed to accord with scientifically
valid guidelines have shown no particular advantage over more ‘traditional’
forms of practice. This point was brought up by most clinicians interviewed,
but not because they didn’t trust scientific method; rather they made this point
in order to dismiss the fake scientific research that is encouraged by institu-
tional policies and guidelines. Dr. Luo spoke of the doubts she had about the
research, owing to the fact that nothing she learned about scientific methods
did anything to improve her clinical effectiveness. Her research verified the
existing ‘why’ of Chinese classical theory, the yin-yang logic that suggested
using yang channel points, such as baihui, to treat yin syndromes. This knowl-
edge, however, cannot be simply and directly translated into clinical situa-
tions. ‘Knowing the how’ does not merely refer to simple clinical formulae or
rote skills. It specifically refers to knowing how to apply the multi-faceted
resources (classic theories, published cases, teacher’s experiences, etc.) of Chi-
nese medicine into ever-various clinical moments.
Many scholars have spoken of a unique mode of knowing in Chinese med-
icine, and elaborated their observations of Chinese doctors’ skills of synthesis-
ing theory and practice in clinical settings.35 Zhang has further argued that the
35
Farquhar 1994a, Hsu 1999, Scheid 2002, Zhang 2007.
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dialectical relationship between inheriting and developing knowledge is the
center of Chinese medical continuity:
Theory or knowledge understood in this sense is not a representation of any
abstract underlying truth or objective principle and therefore is not typically ame-
nable to the absolute judgment of right or wrong. It speaks about the success of a
particular moment with all its contingency and temporality. It becomes truth or
useful knowledge when it becomes relevant to one’s own moment of practice and
thus becomes an integral part of the process of creating that moment. An indi-
vidual physician then becomes a center or a transmitter that is both inheriting and
developing [Chinese medical] knowledge and bringing the past into the present
and the future.36
Any such ‘relevant moment’ for true knowledge is absent in the experimental
animal lab as Dr. Luo and other doctors try to verify classical theories. There-
fore, we can further argue that ‘not knowing the how’ indicates a much bigger
realm of lack than the mere deterioration of clinical skills among the young. It
is a pity that the validity problems involved with scientific research designa-
tions and outcome measurements in Chinese medicine research have not yet
been substantially discussed by Chinese medicine doctors nor seriously con-
sidered by policy makers in China. For example, using sham acupuncture for
control groups in acupuncture trials has failed to prove that ‘sham needling’
actually is sham intervention. The problematic results of much scientific
research are largely due to the ignorance or neglect of the fact that Chinese
medicine including acupuncture and herbal medicine do not work in the same
way as surgery and pharmaceutical drugs. In another words, without knowing
the how, one cannot embark on knowing the why. Otherwise, knowing the
why is irrelevant to what is studied. This explains why Chinese medicine prac-
titioners think scientific research is useless in practice. More importantly,
‘knowing the how’ refers to the pivotal capacity to forge a link between the
past and the present, between classics and clinical reality, between inheriting
older generations’ experience and developing one’s own clinical styles. The
sarcastic play of the proverb, ‘knowing the why but not the how,’ highlights
this poignant situation in the field: the more today’s Chinese medicine doctors
have sought the authority of science to explain why Chinese medicine works,
the less they are able to treat diseases by composing the most effective herbal
or acupuncture prescriptions, as most of them feel the senior doctors of the
past were once able to do.
36
Zhang 2007, p. 26.
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